For discussion and debate about the ethics of health care organizations and the wider health system.

Thursday, June 5, 2008

Hospital Organizational Ethics

The Journal of Medical Ethics recently published an interesting study from the University of Toronto Joint Centre for Bioethics - "Clinical Ethicists' Perspectives on Organizational Ethics in Healthcare Organizations."

The authors interviewed clinical ethicists at eight academic hospitals, four general hospitals, and one community-based care agency in the Toronto area. The participants were asked about the organizational ethics issues their organizations were facing, how these issues were being addressed, and how effective the process was.

The participants identified four major organizational issues:

1. Resource allocation. Canadian hospitals are financed by global budgets negotiated with the provincial health plan. A fixed budget highlights trade off decisions. The ethicists identified having a fair process - a topic my colleague Norman Daniels and I have written about extensively - as a key organizational need. One interviewee commented:

"How do we make decisions about resources in terms of money, as well as staff, and how do other resources get distributed? What model or models of distributive justice or resource allocation...ought we to be considering."

2. Moral distress and organizational moral climate. In the research and consultation I have done, questions like "what keeps you up at night?" and "what do you feel best...and worst about in your work?" have been very productive. Moral distress isn't an infallible sign of an organizational ethics issue. Lucifer was distressed by the conditions in heaven, but that is taken reflect moral failing in Lucifer, not heaven. But investigating moral distress will have high yield for identifying ethical hot spots in an organization.

3. Conflict of interest. Interestingly, the ethicists felt that by and large the hospital policies on financial conflicts set limits on monetary conflicts, and that non-finacial conflicts - prestige, personal advancement, etc were more problematic.

4. Clinical issues with a significant organizational dimension. Clinical ethicists and clinical ethics committees are increasingly encountering major organizational components to issues that are defined as "clinical." The examples cited include decisions about access to care for uninsured patients, decisions related to disclosure of medical error, and a range of issues arising in end-of-life care.

The authors conclude that "the extent to which 'clinical ethics' cases were embedded with an organizational dimension...suggests that the common distinction between clinical and organizational ethics may be overdrawn in the practice of direct patient care...Where once the clinical ethicist's role focused primarily on ethics in discrete clinical or research relationships, its focus is expanding to include ethics in a broader range of organizational relationships and issues."

About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.